MEDICARE: SAN MIGUEL CLINIC CORP DBA NORTHERN NEW MEXICO UROLOGY

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	208800000X	Urology Physician	2000173	NM

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1306830450
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	SAN MIGUEL CLINIC CORP DBA NORTHERN NEW MEXICO UROLOGY

Provider Business Mailing Address
First Line	:	2301 7TH ST
Second Line	:
City	:	LAS VEGAS
State	:	NM
Zip	:	87701-4966
Country	:	US
Telephone Number	:	505-454-4000
Fax Number	:	505-454-4004

Provider Business Practice Location Address
First Line	:	2301 7TH ST
Second Line	:
City	:	LAS VEGAS
State	:	NM
Zip	:	87701-4966
Country	:	US
Telephone Number	:	505-454-4000
Fax Number	:	505-454-4004

Authorized Official
Title or Position	:	UROLOGY
Name	:	DR. AKHIL DAS
Credential	:	MD
Telephone Number	:	505-454-4000

Provider Enumeration Date	:	09/06/2005
Last Update Date	:	08/22/2020

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